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The Influence of Sexuality Education and Supervision

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The Influence of Sexuality Education and Supervision THE INFLUENCE OF SEXUALITY EDUCATION AND SUPERVISION, CLINICAL EXPERIENCE, PERCEIVED SEX KNOWLEDGE, AND COMFORT WITH SEXUAL CONTENT ON THERAPISTS ADDRESSING SEXUALITY ISSUES WITH CLIENTS by KELLl WENNER HAYS, B.A., M.S.Ed. A DISSERTATION IN MARRIAGE AND FAMILY THERAPY Submitted to the Graduate Faculty of Texas Tech University in Partial Fulfillment of the Requirements for the Degree of DOCTOR OF PHILOSOPHY Approved T3 ,TO,^^ ACKNOWLEDGMENTS I would like to express my gratitude and appreciation for Dr. Steven Harris, my committee chair and advisor. His guidance throughout this project and my graduate degree has made me a better researcher and clinician. I would also like to thank my committee members for all of the time that they devoted to helping me successfully complete this project. Specifically, I would like to thank Dr. Dean Busby for his patience with me while he shared his statistical expertise with a novice; Dr. Kary Reid for creating a path to a clinical practice that incorporates and celebrates human sexuality and encouraging others to do the same; Dr. Sheila Garros for the abundance of valuable feedback on my manuscripts and for your passion and expertise for sexuality research. I could not have chosen a more helpfiil and diligent committee. Additionally, I would like to thank my parents for their unending encouragement, love and support. I would not be in higher education if they had not believed in me and instilled a belief in myself The sacrifices that they made on my behalf and for my education have not gone unnoticed or unappreciated. My parents and family have continually supported me throughout my academic endeavors. Nichole Morelock, thank you for being my study partner, stress reducer, and voice of validation during our doctoral program. Most of all 1 would like to thank Nichole, Trina Powers and Amelia Matlack for their friendship and words of encouragement throughout this experience. Lastly. I would like to thank my husband. Buddy. He has been my voice of reason and source of motivation during this project. His never- ending positive attitude has calmed my fears and helped me to find alternative solutions to problems. He has always encouraged me to dream big and has believed that I was capable of reaching those dreams. Thank you for helping this dream to come true. 11 TABLE OF CONTENTS ACKNOWLEDGEMENTS ABSTRACT ii LIST OF TABLES vi LIST OF FIGURES vii CHAPTER viii I. THE PROBLEM Introduction 1 Importance of the Study 1 Statement of the Problem 5 General Hypotheses 6 Definition of Terms 7 Summary 8 II. REVIEW OF LITERATURE 9 Introduction 10 Family Systems Theory 10 Therapist Knowledge About Sex 12 Therapist Sexuality Education 20 Marriage and Family Therapists' Sexuality 24 Education 28 Therapist Comfort with Sexual Matters 31 Summary 34 iii III. PROCEDURES 35 Introduction 35 Restatement of the Problem 35 Description of Sampling Procedure 35 Procedures 36 Instrumentation 39 Sexuality Education scale 41 Clinical Experience scale 41 Experience in Supervision scale 41 Sex Knowledge and Attitude Test (SKAT) 41 Sexual Comfort scale 44 Sexuality Discussions scale 45 Research Questions and Hypotheses 45 Research Design and Analyses 52 Summary 55 IV. RESULTS 56 Introduction 56 Demographic Characteristics of the Sample 56 Preliminary Analyses 61 Tests of Hypotheses 66 Summary 73 iv V. DISCUSSION 75 Introduction 75 Summary of the Study 75 Interpretation of Study Results 78 Methodological Strengths and Limitations 84 Directions for Future Research 88 Clinical Implications for Marriage and Family Therapists 91 REFERENCES 95 APPENDICES 100 A. THE TEXAS TECH UNIVERSITY COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS APPROVAL LETTER 100 B. PRENOTICE LETTER 102 C. COVER LETTER 104 D. QUESTIONNAIRE 106 E. REMINDER POSTCARD 114 F. FOLLOW-UP LETTER AND REPLACEMENT QUESTIONNAIRE 116 G. OMITTED QUESTIONS THAT WERE IDENTIFIED AS QUESTIONABLE BY THE AUTHOR OF THE SKAT 118 H. ADDITIONAL OMITTED QUESTIONS THAT WERE CONSIDERED IRRELEVANT OR OUTDATED 120 ABSTRACT The purpose of this investigation was to examine if marriage and family therapists are initiating sexuality related discussions with their clients. Five variables were hypothesized to either directly or indirectly influence the dependent variable: therapist sexuality education, therapist clinical experience with sexuality issues, experience addressing sexuality issues in supervision, therapist sex knowledge and therapist level of comfort with sexuality issues. The theoretical literature has focused on sexuality education, clinical experience and supervision experience as important in moderating therapists' sex knowledge and comfort with sexuality issues. Previous research also indicates therapists' sex knowledge as an influential factor on therapists' comfort with sexual issues. However, virtually no empirical research has been previously conducted to test these variables. Additionally, there has been no previous empirical research that directly addresses the influencing factors of therapists' willingness to address sexuality issues with clients. A national random sample of 175 clinical members of the American Association for Marriage and Family Therapists (AAMFT) completed a 48-item questionnaire. Participants answered questions that assessed their past, current, and perceived experience and knowledge with sexuality issues. The findings suggest that therapists' perceived sex knowledge is a better predictor of their likelihood to engage in sexuality discussions than their actual sex knowledge. Therapists' comfort with sexual content and sexuality education, both had significant effects on the dependent variable. Implications for these findings are discussed and suggestions for future research are provided. vi LIST OF TABLES 1. Initial Scale Names, Example Questions, and Reliability Scores 2. Measures of Central Tendency and Variance for Demographic Variables 40 3. Demographic Characteristics 58 4. Pearson Correlations for Original Path Model Variables 59 5. Means, Standard Deviations, and Ranges of Variables in the Final Path 63 Model 6. Pearson Correlations for Exogenous and Endogenous Variables 67 7. Decomposition Table 67 72 Vll LIST OF FIGURES 1. Initial Path Model 2. Adjusted Inifial Path Model 53 3. Final Path Model 65 68 Vlll CHAPTER I THE PROBLEM "Sex lies at the root of life, and we can never learn to reverence life until we know how to understand sex." (Havelock Ellis, 1952) Introduction Relevance of Sexuality Discussions in Therapy Therapist-client discussions that address sexuality matters should affirm sexuality and promote sexual health while striving to prevent unsafe sexual sharing (Stayton, 1998). Approached from this perspective, sexuality is understood as an extensive topic that serves as a fundamental component to an overall positive self-esteem (National guidelines task force, 1996). Clients at all ages are dealing with sexuality issues in their life, some more successfully than others. To name a few of the sexually related issues faced during the life cycle: children are learning the names of their body parts as well as developing feelings towards their bodies and specific body parts; adolescents are struggling with sexual expression, values and fears related to developing a sexual identity; couples in committed relationships often encounter matters of sexual satisfaction, frequency, pregnancy, and varied forms of expression; and older adults are facing changes in body, body image and sexual performance. As therapists encourage people to embrace their sexuality, beyond the realms of the act of sexual intercourse, clients are able to conceptualize their sexuality as a positive aspect of their identity. In a study on couples' perceptions of effective and ineffective ingredients of marital therapy, Estrada and Holmes (1999) found that the couples' statements focused 1 largely on the therapists' behavior. Mainly, subjects expected therapists to be active, structured, and focused in therapy while at the same time creating a safe environment. Creating a safe environment for therapy involves creating a non-threatening environment that enables clients to address difficult issues. Thus when therapists initiate conversations about socially labeled taboo topics such as sexuality, their clients may be more willing to initiate discussions involving sexuality in future sessions. In other words, the therapist's ability to initiate sexuality-related discussions with clients serves as a model for future conversations with their clients. Additionally, therapists discussing sexuality issues with clients may provide a model for initiating sexuality-related discussions outside of therapy. For instance, parents will occasionally ask therapists to talk with their children about sexual issues. Likewise, parents will ask therapists for specific ways in which they can discuss sexual issues with their children. In these and similar situations, therapists are sometimes apprehensive to initiate explicit discussions of such issues, which often stems from a lack of knowledge and comfort in the area (White &DeBlassie, 1992). Parents are the earliest and most important influence on sexuality. Parents provide children with their first understanding of gender roles, relationships, body image, values, and their sense of self-esteem. A study by White and DeBlassie (1992) rated parents highest in terms of influence on sexual opinions, beliefs, and attitudes, but lower than friends, school, and books as sources of sexual information. Parents may avoid this area of discussion because
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